Contraception Methods PDF

Services of family planning units - Pregnancy spacing (whether reversible or permanent) - Management of infertility Management of recurrent fetal loss & genetic counseling They could be divided into Hormonal - Combined (Estrogen and Progesterone) OCP.....m...

Services of family planning units - Pregnancy spacing (whether reversible or permanent) - Management of infertility Management of recurrent fetal loss & genetic counseling They could be divided into Hormonal - Combined (Estrogen and Progesterone) OCP.....monthly injectable.......vaginal ring........skin patch - Progesterone only POP....injectable (DMPA)...implants...hormone releasing IUCD Non-hormonal: 1.physiological, 2.barrier, 3.chemical, 4.IUCD, 5.surgical Short acting...........physiologlcal, barrier, chemical, OCPs Long acting............implants, Injectables, IUCD, surgical Irreversible ↓ surgical Reversible ↓ all others Measuring effectiveness (Pearl index) It is method used to determine the pregnancy (Failure) rate among 100 women (HWY) using a contraceptive method for 12 months Perfect use rate→ represents the theoretical efficacy Typical use rate → represents the actual users' experience 1. Most effective-IUCD, contraceptive implants, sterilization 2.Effectlve-Injectables, OCP, transdermal patches, vaginal ring 3. Least effective - diaphragm, cervical caps, condoms, spermicides,withdrawal, and periodic abstinence 99 Ideal contraceptive should be 1.Available 2. Have considerable cost 3. Easily administered 4. Does NOT interfere with coitus 5.Has other non-contraceptive benefits 6. Has least adverse effects 7.The effectiveness is immediate 8. Reversible as soon as its discontinuation The conditions affecting eligibility for the use of each contraceptive method were classified under one of the following four categories: 1] A condition for which there is no restriction for the use of the contraceptive method. 2] A condition where the advantages of using the method generally outweigh the theoretical or proven risks. 3] A condition where the theoretical or proven risks usually outweigh the advantages of using the method. This requires expert medical judgment and/or referral to a specialist. 4] A condition which represents an unacceptable health risk if the contraceptive method is used. With Ilmited clinical Category With clinical judgment judgment 1 Use under any circumstances Yes 99  Yes 2 Generally use the method (use the method) 3 Use is not recommended No 4 Method not to be used (don't use the method) Counseling before using contracepton The method..cost, duration, failure rate, reversibility Technique...............way of usage/ missing-discontinuation /removal Patient....advantage /disadvantage/ contraindication /side effects Safe period: -fertility awareness- * Calendar method - Ovulation occurs at about day 14 of 28 day cycle. - Calculate the length of the last 8 cycles. - First day of abstinence = shortest-18 - Last day of abstinence = longest-11 * Basal body temperature (BBT) -Intercourse is only allowed after ovulation has occurred by3 days - i.e. after 3 days of rise of BBT (a progesterone effect) * Cervical mucus (Billing) method - Intercourse is only allowed after 3 days from disappearance of the vaginal sense of wetness ·Estrogen effect: profuse cervical mucous (wet sensation) ·Progesterone effect: dryness of secretion (after ovulation) - This is not reliable alone. Therefore it is better to use combination (e.g.sympto-thermal method) 100  * Urinary LH kits (Persona): detects ovulation by LH surge in urine ② Lactational amenorrhea method * Idea: The stimulation of the nipples sends nerve impulses to hypothalamus→ release of prolactin → inhibition of GnRH release & hence inhibition of FSH & LH release → inhibition of ovulation. *Increasing efficiency if: -If amenorrhea is still present - Regular breast feeding (6 by day & 2 by night) - No supplementary food is given * Advantage: available from first day, not costy,healthy to infant * Disadvantage - Not so reliable (esp if breakthrough bleeding occur) - Effective mainly in the first 6 months (50%) - Duration of method is limited. Coitus interruptus *Idea→ withdrawal of penis and ejaculation outside the vagina * Advantages → simple, readily avallable with no cost * Disadvantage - Pregnancy may occur in spite of ejaculation outside the vagina as the pre-ejaculatory fluid may contain sperms - Less sexual satisfaction which may lead to pelvic congestion e.g.(menorrhagia, leucorrhea & backache) 1] Condom (latex) 15 x 3.5 x 0.02-0.07 cm ·No side effects or contraindications ·Non contraceptive benefits→ - Protect against STD, PID, CIN - Treatment of immunological infertility - Collection of semen for semen analysis (spermicide free) 101 2] Female condom (vaginal pouch) ·A polyethylene rubber sheath which lines the vagina (17 x 8 cm) ·Has 2 ends L a closed end and an open end 3] Vaginal diaphragm (Dutch cap) 50-95 mm ·Inserted in vagina < IC & removed after 8 hrs (till all sperms die) · Disadvantages - Difficult to apply → needs well training in the clinic - May lead to cystitis if large size, not suitable in prolapse 4] Cervical cap Applied directly to cervlx (22-25-28-31mm) ·Used if there is prolapse (diaphragm can't be applied) 5] Vaginal sponge(Today) ·Synthetic polyurethane sponge containing Nonoxynol-9 · Very easy to insert & remove (up to 24 hours) · Disadv. → Toxic shock syndrome if left long (staph aureus) Advantages Disadvantages No effect on fertillty/ Failure rate → 3-14/HWY (improved by adding spermicidals) lactation No systemic side effects May lead to allergic reaction (latex) Easy to initiate & continue Interrupt natural act (reduce sensation +↑ erectile difficulties) Condom protect against STD Sponge → infection.......Diaphragm→ discomfort *Method Spermicidals→ Nonoxynol-9 & Octoxynol-9 Action → destroy sperm membrane + ↓ O2 uptake *Supplied as foam/jell/cream /effervescent tablets/ supposltories *Use · Inserted 15 min before intercourse ·Intercourse must occur within 2 hours · Delay postcoital douching for 6 hours *Disadvantage:- high failure rate: 30/HWY 102 Made of Polyethylene (non-irritant plastic), with 2 nylon threads Threads act as markers for its presence & facilitates its removal Barium impregnated to make them radio-opaque to confirm their site Types Types Duration 1]Inert Withdrawn from Lippes loop: Double S shaped Indefinite The market 2] Medicated Most With copper 5-10 yr 5yr commonly used now due to: - Cu T 380A (T- shaped device with a copper wire -less pain & around the stem and copper bands on the arms.- Nova T (Novagard) adding silver prolongs life bleeding -better protection span of IUDs (by preventing Cu fragmentation) -Multiload Cu (with vertical stem & two wings with protrusions & Cu wire on vertical stem With progestins (mirena loop) - Levonorgesterel (LNG-IUS) - most recent but expensive Mode of action - The precise mechanism of the contraceptive action of IUDs is not known - Neither ovulation nor steroidogenesis is affected. - IUDs work primarily by preventing fertilization, and do not act as abortifacients.When the uterus is exposed to a foreign body, a sterile inflammatory reaction occurs, which is toxic to sperm and ova and impairs implantation.The production of cytotoxic peptides & activation of enzymes lead to inhibition of sperm motility, reduced sperm capacitation and survival. - By adding progesterone; there is additional: ·Atrophic endometrium ·Thick, scanty, viscid cervical mucus (prevents sperm ascent) ·Prevents sperm capacitation 103 Advantages One decision method & cheap - Left for long periods - Reversible on removal - No systemic effects - No interference with intercourse or lactation - Reliable (failure 0.4-0.6 /HWY )......(0.2 in Levonova) - Non-contraceptive benefits of LNG releasing intrauterine system (IUS): Treatment of dysfunctional uterine bleeding Prevention & treatment of endometrial hyperplasia Protection from PID Disadvantages: 1.Can cause side effects. 2.Trained health provider is needed to insert, follow up and remove the device. 3.No protection against sexually transmitted infections (STI) including HIV,and pelvic inflammatory disease (PID) as well. Contraindications 1. Uterine distortion (preventing proper IUCD application): fibroids or septate uterus 2.History of pelvic infection (PID) or previous ectopic; immunosuppression (steroids, DM, tuberculosis) 3. Undiagnosed amenorrhea (first exclude pregnancy) 4. Undiagnosed bleeding (first detect the cause) 5. Patients with severe anemia, bleeding tendency Complications 1)Bleedlng If occurred post-insertion; reassure after excluding perforation Menorrhagia - Common in the first few cycles following IUCD insertion, but may continue for a variable period after insertion. Bleeding is mostly due to increase prostaglandins production, or increased fibrinolytic activity. Copper IUD increases blood loss by almost 35% in many women. 104  - If Mild to moderate bleeding; give anti-fibrinolytic agents (Tranexamic acid)and/or NSAIDs (as profenid) -If bleeding is severe, /recurrent / persistent; exclude first any organic pathology (as fibroid), and IUCO is better removed. - If the patient prefers using IUD; it is better to use Progesterone releasing IUD as it induces endometrial atrophic changes with 70% reduction in menstrual blood loss 2)Pain During or after insertion: slight cramping pain is normal, severe pain may occur due to forcible cervical dilatation, abnormal IUD position, or uterine perforation.Backache: due to pelvic congestion, or chronic cervicitis. Acute abdomlnal paln: you must exclude PID, abortion, disturbed ectopic pregnancy, uterine perforation. 3) PID Slight increased risk of PID especially during the 1st month. Mostly due to introduction of bacteria from the lower genital tract during IUD insertion (threads act as a leader for organism). Prevention: - Screen the potential users for STIs, and assess for their risk - Sterile techniques during insertion. 4) Expulsion (especially during menses) Predisposing factors - Young age or nulliparity -Local abnormality of uterus/cervix -If inserted occurred immediately postpartum or pregnancy occurred - Too large or too small IUCD / bad technique on insertion Types -Complete expulsion; the IUD will be expelled out the cervix, into the vagina. - Incomplete: the IUD is displaced within the endocervical canal Management: In both cases IUD should be removed and correctly re-inserted 5) Perforation (a rare but potentially serious complication) Predisposing factors - Same as for IUD expulsion 104  - But the risk is linked to the skil and experience of the provider. May occur during - Insertion: severe persistent pain & vaginal bleeding - Gradual perforation later on may lead to PID (2ry) or missed threads 6) Pregnancy Intra-uterine (0.5 /HWY) -Due to.. misplacement, perforation, expulsion - Presents as.........amenorrhea - There is risk of........septic abortion, PROM, pre-term labor - Management:- If threads accessible: remove with 25 % risk of abortion If not accessible: continue with 50 % risk of abortion (with increased risk of sepsis but no increase in percentage of congenital anomalies) Extra-uterine (1-2/10.000) due to - Associated tubal infection - Decreased tubal motility (due to progesterone in mirena) - IUD prevents intrauterine but not extra-uterine pregnancy 7) Missed threads (Missed loop) Etliology - Patient could not be able to feel threads. - Cervical or vaginal infection with threads stuck to the cervical mucous - Enlarging uterus due to pregnancy or a gynecologic cause. - Perforation of the uterus with intraabdominal placement of the IUD. 105  - Expulsion. Work up - Exclude pregnancy (U/S + pregnancy test) - Try to find threads in vagina by speculum - Trans-vaginal ultrasound -If not found ·Plain X-ray (both antero-posterior ± lateral view with uterine sound) ·Hysteroscopy Management - If intra-uterine → hysteroscopic removal or D&C - If extra-uterine→ remove by Laparoscopy Before use: Counsel the patient for Type & duration of IUCD Failure rate Warning signs -Missing threads/period -Severe pain/ discharge / bleeding Timing Post-menstrual (cervix is somewhat patulous, avoiding pregnancy) - Post-abortion (by one week) - Post-partum (after first 48 hours or after puerperium) Post-coital (emergency) contraception During cesarean (Gynifix) Technique of insertion No need for anesthesia (just 2 suppositories anti-prostaglandins) -Lithotomy position - Bimanual examination to know the size, position, any contraindication - Cusco speculum and sterilize cervix by antiseptic solution - Grasp anterior cervical lip by volsellum 106  - Uterine sounding to know the length & direction of uterus The withdrawal technique ·Used for copper devices ·The inserter is introduced to reach near uterine fundus.The plunger rod is used to fix the IUD near the fundus, while the outer sheath is gently withdrawn back releasing the limbs of the IUD with its 'T'arms spreading towards each uterine cornu ·The nylon threads are then cut 2 cm from the cervix ·This technique reduces incidence of uterine perforation as compared to the previously used "push out" technique Follow up - The patient is examined after the next menses & then every year Self-examination after each menstruation to feel threads Indications of removal - When pregnancy is desired -If pregnancy occur - If complications occur - Each device has a certain half life - After menopause (usually by one year) 1. COC pills Composition:- Estrogen used Ethinyl estradiol(EE) Mestranol: it is less potent than EE. Estradiol valerate Progestagen (gestagen) used 106  First generation Estrane...Noresthisterone, Norethindrone, Norgestrel Pregnane........Medroxy progesterone acetate Second generation: Levonorgestrel Third generation: more potency with less androgenic side effects Desogestrel.................Marvelone - Gestodene.................Gynera Norgestimate....Cilest Fourth generation: drospirenone........Yasmin (Yaz) Types Monophasic pills; contain the same estrogen / gestagen content in one phase High dose: 50 μg EE - Moderate dose: 30-35 μg EE - Low dose: 15-20 μg EE Biphasic pills; pills contain different estrogen / gestagen content in two phases (first phase 10 days and second phase 11 days having double progesterone content) follwed by a 7 -day pill free interval. ③ Triphasic pills; pills contain different estrogen / gestagen concentration in three phases (1st phase 6 days, 2nd phase 5 days, 3rd phase 10 days)followed by a 7 -day pill free interval. Gestagen contents are increased from phase one through phase three, imitating the natural cycle,aiming at minimizing side effects especially break through bleeding. Mode of action 1. Estrogen: inhibits ovulation via suppression of Gn RH, pituuitary FSH and LH(it is the primarily mechanism of action) 2.Progestogen: - Endometrial glandular atrophy → unfavorable for implantation. - Cervical mucous thickening → hostile to sperm penetration - Altered tubal motility → unfavorable for oocyte transport - Interference with ovulation; through FSH/LH suppression (but less than estrogen) Advantages 107  * Contraceptive -Failure rate =0.1 / HWY (most effective method) - Cheap, easy to use, available, not related to intercourse - Rapidy reversible with return to ovulation once stopped *Non contraceptive benefits 1. Improve rhythm & amount of menstrual cycle 2.Control of dysfunctional uterine bleeding 3.Decreased menorrhagia → decreased anemia 4.Improve dysmenorrhea & premenstrual tension 5. Decrease incidence of fibroids, endometrial carcinoma 6.Improve functional ovarian cyst and endometriosis 7.Decrease benign breast lesions 8. Decreased PID risk (thick cx mucus) 9. Decrease the risk for ectopic pregnancy Disadvantages 1. Incorrect use is common, and that increases failure rate. 2.Require daily use. 3. Re-supply is required. 4. No protection against STI including HIV. 5. May pose health risks fora small number of women. Pill administration Choice of pills → better to use -Low dose estrogen pills (less estrogen side effects with same potency) - There are no proven benefits for biphasic or triphasic COC over monophasic pills; hence their use has not gained enough popularity. -Pills containing new progesterone generation has less androgenic side effects Starting pills - Started day 2-4 of the menstrual cycle and continued daily for 21 days.followed by a 7-day pill free period. Menstruation usually occurs 3-4days after discontinuation of the last pill. 108  -The 28 pack contains 7 days of iron (norminest Fe) -May start 4-6 weeks after labor (non-lactating) or 1-2 weeks after abortion Missing pills -If one pill is forgotten → take one as soon as possible then the next pill is taken at usual time - If two pills are missed → as above bu extra-precaution backup for the rest of cycle(e.g. condom). If less than 7 pills are remaining in the packthen start a new pack on the next day (thus omitting the usual seven day free interval) Drug interactions with - Sedatives, anti-epileptics, anti-histaminic - Some antibiotics, anticoagulants Side effects & Complications Major side effects 1. Increased risk for cardiovascular complications (e.g. thrombosis and stroke):especially after long- term use & mainly in the high-risk groups - Estrogen increase platelet adhesiveness, and factors ll, VII, IX, and X - Progestins decrease circulating HDL, increase LDL, and have adverse effects on the glucose tolerance. These effects are dose-dependent. 2. There is no overall increase i the risk of breast cancer: - Premenopausal breast cancer: Long-term use before childbearing may slightly increase risk. (may be due to detection bias due to meticulous screen in COC users). - Postmenopausal breast cancer: the risk does not increase and might drop. 3. Small increase in the risk of cervical cancer, an associated statistical fiding due to increased incidence of HPV infection in the pill users only in wester countries (more frequently subjected to increased sexual activity and multiple sexual partners & increased cigarette smoking). Menstrual side effects 1.Spotting: Minimal bleeding especially midcycle (more common with POP and Triphasic OCPs), mostly due to inappropriate hormone content of the pill. In such cases shift to other preparation with higher dose of hormones in the following cycles. 2. Breakthrough Bleeding; inter-menstrual bleeding during the course of pill taking is also managed by shifting to higher hormone content pills if the condition persists after the first three months. 3. Hypomenorrhea: It is common with OCP as gestagens cause glandular atrophy. Pills should be stopped if the symptom is unacceptabe. 108  4. Amenorrhea: during intake or immediately after stopping the pills (post pill amenorrhea): is managed by excluding pregnancy, inducing withdrawal bleeding by gestagens, or may shift to another non hormonal method.Other side effects: 1. Nausea and vomiting: may be encountered in the first few cycles. 2. Migraine headache: if severe needs discontinuation or shift to other method 3. Imitability and depressive mood: Shift to lower progestogen content pills. 4.Weight Gain:usually minor, mainly due to salt and water retention. 5. Breast engorgement, tenderness, and enlargement: shift to lower E/P pills 6. Acne: may worsen during OCP intake. If already present use Diane 30 OCP (EE: 30ug +Cyproterone acetate 2 mg). 7. Skin Pigmentation: as chloasma similar to that of pregnancy 8.Change in Libido: decreased sexual desire may rarely occur in some women. 9. Vaginal Discharge: Leucorrhoea may occur due to cervical congestion. 10.Eye Symptoms: corneal edema, contact lens wearers suffer from blurring of vision & corneal irritation. Reported cases of transient optic nerve ischemia, and transient blurring of vision. Contraindications Absolute Relative 1. Thrombophlebitis or thromboembolic dis. 1. Superficial thrombophlebitis 2. History of DVT. 2. Varicose veins. 3. Coronary heart disease 3.Migraine headache / Epilepsy 4. Cerebrovascular accidents or strokes 4.Hypertension Diabetes mellitus 5.Estrogen-dependent malignant 5. Age ≥ 35 years with any of the following tumors:carcinoma of the breast and uterus.- risk factors: (hypertension, DM,hyper- History of hepatic adenoma lipidemia, heavy smoking) 6. Markedly impaired liver function. 6.Gall bladder stones 7. History of cholestasis during pregnancy 7. Sickle cell disease or sickle C disease. 8.Pregnancy 8. Undiagnosed genital bleeding 2. POP (Minipills) Preparation (pills containing very small amount of progesterone) 109  - Levonorgestrel: Microlut (30 μg) - Noresthisterone: Micronor(350 μg) -Lynestrenol: Exluton - Desogestrel: Cerazette Mode of action - Mainly by rendering cervical mucous thick - Also, progesterone renders endometrium atrophic & inhibits sperm capacitation - To less extent → alter tubal motility & suppression of ovulation (50%) Use - One tablet is taken daily from the first day of the cycle continuously at the same time (35 tablet /pack) - If forgotten or delayed ≥ 3 hours→ continue backup for 14 days Indications -Lactating patients - No E side effects suitable for cardiac, hepatic, over 40 and smokers -As there is minimal progesterone: it could be given for diabetics,hypertensives and Obese Disadvantages & side effects -Higher failure rate than combined pills = 1-2 /HWY - Liability to ectopic pregnancy (due to effect on tubes) - Menstrual side effects e.g. Spotting or Irregular cycles Contraindications - Undiagnosed amenorrhea -Undiagnosed genital bleeding - Previous ectopic pregnancy 3. Injectables Forms Progestin-only injectables: 110  -Depo-Provera 150 mg (DMPA)...IM/3 months - Depo-subQ Provera 104 mg (DMPA)...SC/3 months - Norethisterone enanthate IM/2 months Combined injectables: given monthly - Cyclofem (DMPA 25 mg + estradiol cypionate 5 mg) - Mesigyna (DMPA 50 mg + estradiol valerate 5 mg) Mode of action - Mainly by thickening cervical mucus → difficult for sperm to enter uterine cavity - Also, by suppression of ovulation by suppressing FSH and LH. Advantages 1. Available and usually non costy. 2.Require no action at the time of intercourse. 3. Have no effect on lactation and can be used by breastfeeding women. 4. It does not affect the overall risk of breast cancer (small increase reported may be due to early diagnosis as DMPA users regularly visit health providers). 5.Safe and highly effective (more than 99%). 6. Long acting, but with delayed reversibility 7.Offer non-contraceptive health benefits. - Protects from endometriosis, endometrial hyperplasia or carcinoma - Improves pre-menstrual tension & dysmenorrhea - Treats precocious puberty, hirsutism - Protects against PID (but not STD) Side Effects & disadvantages: Progestin-only injectables: 1. Menstrual irregularities: Irregular bleeding / spotting and amenorrhea (more common for progesterone only than with combined injectables) 2.Weight gain (more common for progestin-only injectables). 3. Return to fertility after discontinuation is usually delayed. It takes an average of 9 months for a woman to achieve pregnancy after last injection. 111  4. It decreases bone density (bone loss is reversible especially in the older women). young women could have an increased risk of developing osteoporosis later in life. 5. No STI/HIV protection. Combined injectables 1. Side effects profile is typical of low-dose COC: Headache, dizziness, breast tenderness and mood changes. 2. But with better control on the cycle. 4.Subderma Implants Method Implanon - is a Single cylinder left for 3 years that contains "etonogestrel" -It recently replaced Norplant (FDA approved 2006) Nexpalnon - It is a single rod containing 68 mg of etonogestrel left for 3 years. Action - Mainly by thickening cervical mucus → difficult for sperm to enter uterine cavity - Also, by suppression of ovulation by suppressing FSH and LH. Advantage - Long acting (99% protection) - Action is rapidly reversible after removal with rapidly restoring fertility - No side effects of estrogen (can be used for lactating) Disadvantage - Headache / breast tenderness / weight gain - Difficult insertion & removal (needs provider's help) - Menstrual irregularities (spotting / prolonged bleeding / amenorrhea). These changes in the menstrual pattern are the most common reason that women request removal during the first 2 years after insertion. 111  - Provides no protection against STI, including HIV. 5. Vaginal contraceptive ring Combined vaginal ring (EE + Etonogestrel) - As COC (insered for 3 weeks & removed for 1 week) - Failure rate = 0.5/HWY Advantage of vaginal rings -Immediately reversible - Simple introduction & removal - Fewer side effects (bypass first effect of hepatic metabolism) 6. Combined hormone patches - Evra patch for 3 weeks and then removed 1 week. Failure rate 1.2/HWY 7. Hormone releasing IUCD (LNG -IUS) Types Male: Bilateral Vasectomy - Via single supra-pubic incision (done under local anesthesia) - Very easy & simpler procedure than female → use backup for 12 week -Efficiency confirmed by 2 -ve semen analysis Female:Tubal Ligation - Laparoscopy: electrocoagulation of tube or application of a Falope ring or clip - Hysteroscopic: Tubal occlusion (by cyanoacrylate with immediate effect or application of Essure with delayed effect & more side effects) - Minilaparotomy: ligation of a part of the tube (Pomeroy method) - Postpartum At cesarean section (common) / After vaginal delivery (2-3 days later via a small sub- umbilical incision) Indications -Permanent contraception 112  - Completed family, old couple (> 35 year old) → with failed all other methods - Contraindication for pregnancy → scarred uterus,very serious illness -Contraindicated in young uncertain couple with marital or mental problems Complications -Complications of anesthesia or surgery (infection, bleeding, bowel injury) - Pregnancy (Failure)→ 0.1-0.4/HWY due to Recanalization (especially postpartum) Faulty technique -Post-ligation syndrome Menorhagia & congestive dysmenorhea months or years after the procedure. Mostly due to interference with ovarian venous retum causing pelvic congestion Male contraception Permanent: vasectomy Temporary: Physiological..coitus interruptus & interfemoris Mechanical. male condom Chemical..........Gossypol (inhibits mitochondria & motility) Hormonal.............progesterone / danazol/LHRH analogues Immunological...vaccines against sperm antigens, zona pellucida Postpartum contraception Immedlately Breast-feeding,Barriers,sterilization Lactating women at 6 wks Progestagen only methods (POP, DMPA, implants) IUCD Lactating women at 6 months: as above + Methods containing E ·COC ·Combined monthly injectable ·VCR (vaginal contraceptive ring) Postcoital (emergency) contraception 113  Hormones Given immediately or within 72 hours (the morning after-plll) They inhibit ovulation and cause early luteolysis (interception) They usually cause nausea and vomiting (antiemetic must be added) 1. POP: Contrpaln Il / Plan B (750ug levonorgestrel): 1 tab, repeat after 12 hours 2. High dose COC (Yuzpe regimen) 2 tablets...............repeat after 12 hours 3.Anti-progesterone e.g. Ulipristal (selective progesterone receptor modulator) 4. Anti-gonadotrophin e.g. Danazol 600 mg...............repeat after 12 hours Mechanical IUCD is inserted immediately even up to 120 hours It is the most effective method for emergency contaception (FR=1%) Menstrual aspiration: suction of the uterine contents by Karman cannula Special groups Dlabetics Better to avoid estrogen containing components IUCD may be Inserted with precaution for possible infections For Rheumatlc heart disease Better to avoid estrogen containing components IUCD may be inserted with precaution for risk of infective endocarditis Newly married Best is hormonal contraception (COC) Injectable contraception have delayed reversibility Local methods have higher failure rate with difficulty in use IUCD is better not to be used Smokers Better to avoid estrogen containing components Elderly 114  IUCD is better Progesterone containing contraceptives are more suitable Permanent sterilization is considered Contraindications for pregnancy Mother 1.High risk pregnancy (certain cardiac conditions) 2. Infection (Rubella).....Vaccination (MMR) 3. Drugs (e.g. acne therapy with retinoic acid -6 m at least) Uterus...scarred with liability to rupture 114